Provider Demographics
NPI:1629280359
Name:CHARLES P. LAWLESS, M.D., P.A.
Entity Type:Organization
Organization Name:CHARLES P. LAWLESS, M.D., P.A.
Other - Org Name:WALT'S OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PITTMAN
Authorized Official - Last Name:LAWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-232-4133
Mailing Address - Street 1:1777 E CLARK ST STE 310
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3357
Mailing Address - Country:US
Mailing Address - Phone:208-232-4133
Mailing Address - Fax:208-233-5736
Practice Address - Street 1:1777 E CLARK ST STE 310
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-232-4133
Practice Address - Fax:208-233-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3434174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005308OtherREGENCE BLUE SHIELD OF ID
ID07302OtherBLUE CROSS OF IDAHO
ID1110597Medicare ID - Type Unspecified
ID000010005308OtherREGENCE BLUE SHIELD OF ID
IDB63305Medicare UPIN